Rate Control In Atrial Fibrillation Research Articles

Comparison of the Effectiveness and Safety of Metoprolol and Diltiazem in Atrial Fibrillation With Rapid Ventricular Rate Patients: A Systematic Review and Meta-Analysis.

This study aims to assess the association between intravenous diltiazem and metoprolol in rate control for atrial fibrillation (AF) patients with rapid ventricular rate, focusing on rate control efficacy and hemodynamic adverse events. Following thePreferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, electronic searches were conducted in Embase, PubMed, and Cochrane CentralRegister of Controlled Trials (CENTRAL) until February 20, 2024. The primary outcome was achieving ventricular rate control < 110/min. Secondary outcomes included new hypotension (systolic blood pressure < 90 mm Hg) and bradycardia (heart rate < 60/min). Nineteen studies (three randomized controlled trials and 16 observational studies) were included in this meta-analysis. Pooled analysis showed intravenous metoprolol resulted in a 39% lower rate control attainment compared to diltiazem (OR: 0.61; 95% CI: 0.44 to 0.84; p = 0.002). There were no significant differences in bradycardia (OR: 0.51; 95% CI: 0.22 to 1.22; p = 0.13) or hypotension risk (OR: 1.08; 95% CI: 0.72 to 1.61; p = 0.72) between the two groups. Intravenous diltiazem demonstrated superior rate control efficacy compared to metoprolol in AF patients with rapid ventricular rate. However, no significant differences were observed in safety outcomes, namely, bradycardia and hypotension.

An Update on Hypomagnesemia and Hypermagnesemia

Magnesium is an essential element with a pleiotropic role in human biology. Despite tight intestinal and renal regulation of its balance, insufficient intake can finally result in hypomagnesemia, which is a proxy of intracellular deficiency. Conditions such as diabetes, cancer, and infections are often associated with hypomagnesemia, which mostly predicts an unfavorable outcome. The effects of hypomagnesemia can either be direct and include neurological and cardiovascular symptoms or indirect, taking a mechanistic role in inflammation, endothelial dysfunction, and oxidative stress. The indication for intravenous magnesium as a treatment of torsades de pointes and pre-eclampsia is unrefuted, but new indications of peroral or intravenous supplementation, albeit with less supporting evidence, have emerged suggesting, respectively, an attenuation of vascular calcification in chronic kidney disease and improved rate control in atrial fibrillation. Other potential beneficial properties of magnesium, which were claimed by observational data, such as lipid lowering and renal protection, were not, or only partially, investigated in randomized controlled trials. Thus, the role of peroral supplementation of mild chronic asymptomatic hypomagnesemia should be separated from the more targeted prescription of magnesium in specific study populations. (Severe) hypermagnesemia is potentially life-threatening and occurs almost uniformly in subjects with severe renal failure exposed to either supplements or to magnesium-containing cathartics or antacids. Moderate hypermagnesemia is very common in pre-eclamptic women treated with intravenous magnesium. For most (but not all) studied endpoints, mild hypermagnesemia yields a survival benefit. Long-lasting concerns about the potential negative effects of mild hypermagnesemia on bone physiology and structure have so far not been unequivocally demonstrated to be troublesome.

The new European Society of Cardiology guideline for the management of cardiomyopathies: key messages for cardiac electrophysiologists.

Electrocardiographic findings and arrhythmias are common in cardiomyopathies. Both may be an early indication of aspecific diagnosis or may occur due to myocardial fibrosis and/or reduced contractility. Brady- and tachyarrhythmias significantly contribute to increased morbidity and mortality in patients with cardiomyopathies. Antiarrhythmic therapy including risk stratification is often challenging and plays amajor role for these patients. Thus, an "electrophysiological" perspective on guidelines on cardiomyopathies may be warranted. As the European Society of Cardiology (ESC) has recently published anew guideline for the management of cardiomyopathies, this overview aims to present key messages of these guidelines. Innovations include anew phenotype-based classification system with emphasis on amultimodal imaging approach for diagnosis and risk stratification. The guideline includes detailed chapters on dilated and hypertrophic cardiomyopathy and their phenocopies, arrhythmogenic right ventricular cardiomyopathy, and restrictive cardiomyopathy as well as syndromic and metabolic cardiomyopathies. Patient pathways guide clinicians from the initial presentation to diagnosis. The role of cardiovascular magnetic resonance imaging and genetic testing during diagnostic work-up is stressed. Concepts of rhythm and rate control for atrial fibrillation have led to new recommendations, and the role of defibrillator therapy in primary prevention is discussed in detail. Whilst providing general guidelines for management, the primary objective of the guideline is to ascertain the disease etiology and disease-specific, individualized management.

Abstract 15597: Unlocking Rate Control in Atrial Fibrillation: A Closer Look at the Intravenous Diltiazem and Metoprolol Duel - An Updated Systematic Review and Meta-Analysis

Background: Intravenous beta-blockers and calcium channel blockers remain first-line therapeutic agents for hemodynamically stable atrial fibrillation patients with a rapid ventricular rate (AF-RVR) in emergency medical settings. Material and Methods: We conducted a thorough review of various sources, including PubMed, Embase, Cochrane databases, and clinicaltrials.gov registry. Our search covered the period from the inception of these databases up to May 20, 2023. We only selected studies that compared the effectiveness and safety of diltiazem and metoprolol in adult patients with AF-RVR who were in emergency medical settings or hospitalized. We focused on whether the drugs successfully controlled heart rate and if there were any cases of hypotension or bradycardia following drug administration. Results: Among the 150 identified studies, 19 were suitable. All these studies demonstrated a low to moderate risk of bias. The meta-analysis, using the Mantel-Haenszel random-effects model, revealed a higher success rate in achieving the rate control target with diltiazem compared to metoprolol [19 studies, n = 1732, Odds Ratio (OR): 1.65; 95% Confidence Intervals (CI):1.18 to 2.32; I^2 = 58%, P = 0.001]. In terms of safety, no significant difference was observed in the risk of hypotension with either drug [15 studies, n = 1477, OR: 1.12; 95% CI: 0.76 to 1.64; I^2 = 25%, P = 0.18]. However, an incidence of bradycardia was noticed with diltiazem [7 studies, n = 1203, OR: 2.85; 95% CI: 1.25 to 6.46; I^2 = 21%, P = 0.27]. Conclusions: For patients with AF-RVR, intravenous diltiazem was more successful in achieving the desired rate control than metoprolol. Both drugs had similar rates of hypotension, but diltiazem had a slightly higher risk of bradycardia. These results indicate that diltiazem may be a better option for rate control in AF-RVR patients. However, high-quality randomized studies are needed to assess both medication's long-term safety and effectiveness in this group.

A pilot study evaluating the role of ivabradine for rate control in patients with rheumatic atrial fibrillation

ObjectivesIvabradine may have a role in rate control of atrial fibrillation (AF) due to effects on HCN channels in AV node. We studied role of Ivabradine in rate control of rheumatic AF. Methods80 patients, rheumatic AF, HR > 100 bpm (age 47 ± 11 yrs, AF duration 6.8 ± 2.9 years, rate 131 ± 16 bpm) on maximally tolerated ββ or CCB's, randomized to Ivabradine or escalated ββ/CCB. Ivabradine started @ 2.5 mg BD; increased to 5 mg BD if inadequate response at 1 week (failure to decrease HR < 10% vs baseline). After Holter at 1 month, dose escalated to 7.5 mg BD if needed. ResultsIvabradine resulted in significantly lower HR (81 ± 10 vs 99 ± 9) at 3 months and 6 months (79 ± 8 vs 94 ± 8, p < 0.001). Absolute reduction in HR: 56 ± 15 vs 31 ± 14 bpm and % change in HR: 41 ± 7 vs 24 ± 9%, both p < 0.00001).At 6 months, Ivabradine group had.1Significantly lower NT Pro BNP (1168 vs 1314 pg/ml), higher 6 min walk distance (410 ± 47 vs 349 ± 54 m, all p < 0.001)2Better symptom class (EHRA score 1: asymptomatic 84% vs 40%), improvement >1 EHRA class; baseline 60% vs 17%3Better LA Strain (22.8 ± 2.8% vs 20.6 ± 2.5%)Ivabradine was well tolerated and there was no drug withdrawal. ConclusionOur data suggest that Ivabradine can be an option for rate control in rheumatic AF.

Efficacy and safety of intravenous beta-blockers in acute atrial fibrillation and flutter is dependent on beta-1 selectivity: a systematic review and meta-analysis of randomised trials

BackgroundIntravenous beta-blockers are commonly used to manage patients with acute atrial fibrillation (AF) and atrial flutter (AFl), but the choice of specific agent is often not evidence-based.MethodsA prospectively-registered systematic review and meta-analysis of randomised trials (PROSPERO: CRD42020204772) to compare the safety and efficacy of intravenous beta-blockers against alternative pharmacological agents.ResultsTwelve trials comparing beta-blockers with diltiazem, digoxin, verapamil, anti-arrhythmic drugs and placebo were included, with variable risk of bias and 1152 participants. With high heterogeneity (I2 = 87%; p < 0.001), there was no difference in the primary outcomes of heart rate reduction (standardised mean difference − 0.65 beats/minute compared to control, 95% CI − 1.63 to 0.32; p = 0.19) or the proportion that achieved target heart rate (risk ratio [RR] 0.85, 95% CI 0.36–1.97; p = 0.70). Conventional selective beta-1 blockers were inferior for target heart rate reduction versus control (RR 0.33, 0.17–0.64; p < 0.001), whereas super-selective beta-1 blockers were superior (RR 1.98, 1.54–2.54; p < 0.001). There was no significant difference between beta-blockers and comparators for secondary outcomes of conversion to sinus rhythm (RR 1.15, 0.90–1.46; p = 0.28), hypotension (RR 1.85, 0.87–3.93; p = 0.11), bradycardia (RR 1.29, 0.25–6.82; p = 0.76) or adverse events leading to drug discontinuation (RR 1.03, 0.49–2.17; p = 0.93). The incidence of hypotension and bradycardia were greater with non-selective beta-blockers (p = 0.031 and p < 0.001).ConclusionsAcross all intravenous beta-blockers, there was no difference with other medications for acute heart rate control in atrial fibrillation and flutter. Efficacy and safety may be improved by choosing beta-blockers with higher beta-1 selectivity.Graphical abstract

Safety and Efficacy of Nondihydropyridine Calcium Channel Blockers for Acute Rate Control in Atrial Fibrillation with Rapid Ventricular Response and Comorbid Heart Failure with Reduced Ejection Fraction.

The use of nondihydropyridine calcium channel blockers (NDCCBs) to achieve rate control in atrial fibrillation with the rapid ventricular rate (AF RVR) is not recommended in patients with comorbid heart failure with reduced ejection fraction (HFrEF) due to the concern for further blunting of contractility. However, these recommendations are extrapolated from data examining chronic NDCCB use in HFrEF patients, and comorbid AF was not analyzed. These recommendations also do not cite the hemodynamic effects or clinical outcomes of NDCCBs for acute rate control in HFrEF patients with AF RVR. It is our goal to open the discussion concerning the hemodynamic effects and safety profile of NDCCBs for acute rate control in this specific patient population. In the acute setting of AF RVR and HFrEF, there is a paucity of low-quality data on the safety and hemodynamic effects of NDCCBs, with mixed results. There has not been a clear signal toward adverse outcomes with NDCCBs, particularly for diltiazem. Data in this scenario is similarly limited for beta blockers, which provide the additional hemodynamic effect of the neurohormonal blockade, which provides a long-term mortality benefit to HFrEF patients. We support the cautious use of beta blockers as first-line therapy in clinical settings where an acute rate control strategy for AF RVR is warranted. We also support diltiazem as a reasonable second-line option, though the relative paucity of data calls for further research to validate this conclusion. Verapamil in this setting should be avoided until more data are available.

Rate control in atrial fibrillation, calcium channel blockers versus beta-blockers

ObjectiveTo investigate heart rate differences between non-dihydropyridine calcium channel blockers and beta-blockers in patients with non-permanent atrial fibrillation (AF).MethodsUsing data from ‘A Comparison of Rate Control and Rhythm Control in...

Ivabradine for controlling heart rate in permanent atrial fibrillation: A translational clinical trial

Pharmacological options for rate control in atrial fibrillation are scarce. Ivabradine was postulated to reduce the ventricular rate in this setting. The objectives of this study were to evaluate the mechanism of inhibition of atrioventricular conduction produced by ivabradine and to determine its efficacy and safety in atrial fibrillation. The effects of ivabradine on atrioventricular node and ventricular cells were studied by invitro whole-cell patch-clamp experiments and mathematical simulation of human action potentials. In parallel, a multicenter, randomized, open-label, phase III clinical trial compared ivabradine with digoxin for uncontrolled permanent atrial fibrillation despite β-blocker or calcium channel blocker treatment. Ivabradine 1 μM inhibited "funny" current and rapidly activating delayed rectifier potassium channel current by 28.9% and 22.8%, respectively (P < .05). The sodium channel current and L-type calcium channel current were reduced only at 10 μM. Ivabradine slowed the firing frequency of a modeled human atrioventricular node action potential by 10.6% and induced a minimal prolongation of ventricular action potential. Thirty-five (51.5%) patients were randomized to ivabradine and 33 (49.5%) to digoxin. The mean daytime heart rate decreased by 11.6 beats/min (-11.5%) in the ivabradine arm (P = .02) vs 19.6 (-20.6%) in the digoxin arm (P < .001), although the noninferiority margin of efficacy was not met (Z = -1.95; P = .97). The primary safety end point occurred in 3 patients (8.6%) on ivabradine and in 8 (24.2%) on digoxin (P = .10). Ivabradine produced a moderate rate reduction in patients with permanent atrial fibrillation. The inhibition of funny current in the atrioventricular node seems to be the main mechanism responsible for this reduction. Compared with digoxin, ivabradine was less effective, was better tolerated, and had a similar rate of serious adverse events.

Lenient rate control versus strict rate control for atrial fibrillation: a statistical analysis plan for the Danish Atrial Fibrillation (DanAF) randomized clinical trial

BackgroundA key decision in the treatment of atrial fibrillation is choosing between a rhythm control strategy or a rate control strategy as the main strategy. When choosing rate control, the optimal heart rate target is uncertain. The Danish Atrial Fibrillation trial is a randomized, multicenter, two-group, superiority trial comparing strict rate control versus lenient rate control in patients with either persistent or permanent atrial fibrillation at inclusion. To prevent bias arising from selective reporting and data-driven analyses, we developed a predefined description of the statistical analysis.MethodsThe primary outcome of this trial is the physical component score of the SF-36 questionnaire. A total of 350 participants will be enrolled based on a minimal important difference of 3 points on the physical component score of the SF-36 questionnaire, a standard deviation of 10 points, a statistical power of 80% (beta of 20%), and an acceptable risk of type I error of 5%. All secondary, exploratory, and echocardiographic outcomes will be hypothesis-generating. The analyses of all outcomes will be based on the intention-to-treat principle. We will analyze continuous outcomes using linear regression adjusting for “site,” type of atrial fibrillation at inclusion (persistent/ permanent), left ventricular ejection fraction (≥ 40% or < 40%), and the baseline value of the outcome (all as fixed effects). We define our threshold for statistical significance as a p-value of 0.05 and assessments of clinical significance will be based on the anticipated intervention effects defined in the sample size and power estimations. Thresholds for both statistical and clinical significance will be assessed according to the 5-step procedure proposed by Jakobsen and colleagues.DiscussionThis statistical analysis plan will be published prior to enrolment completion and before any data are available and is sought to increase the validity of the DANish Atrial Fibrillation trial.Trial registrationClinicaltrials.gov NCT04542785. Registered on Sept 09, 2020.

Implementation of a clinical decision support alert to prevent use of intravenous β-blockers and nondihydropyridine calcium channel blockers in hospitalized patients with acute decompensated heart failure.

Intravenous (IV) β-blockers (BBs) and nondihydropyridine calcium channel blockers (NDCCBs) are harmful in patients with acute decompensated heart failure (ADHF), but they are commonly used for rate control in atrial fibrillation (AF). This study evaluated the implementation of a clinical decision support (CDS) alert in the electronic health record (EHR) to prevent the use of these agents for AF in patients with ADHF, as well as results from the alert's continuous quality improvement. This was a single-center, retrospective, quasi-experimental pre/post analysis of hospitalized adult patients with an ejection fraction of less than 40% documented during their encounter. Groups corresponding to encounters before and after introduction of the alert were compared, and the first version of the alert was compared to its second version that was refined by iterative design. For all patient hospital encounters, the rate of IV BB and NDCCB orders decreased in the period after alert implementation from 16.2% to 12% (P < 0.001). The alert's override rate decreased from 83.8% for the first version to 70.1% after iterative design (P = 0.015). This study demonstrates that a CDS alert can be used in the EHR to reduce the use of potentially harmful IV BBs and NDCCBs in patients with ADHF for rate control. User compliance with the alert was improved by applying human factors design principles and iterative design during continuous quality improvement.

Ultrasound-mediated piezoelectric nanoparticle modulation of intrinsic cardiac autonomic nervous system for rate control in atrial fibrillation.

Rate control is a cornerstone of atrial fibrillation treatment. Barium titanate nanoparticles (BTNPs) are piezoelectric nanomaterials that can generate local electromagnetic fields under ultrasound activation, stimulating nearby neuronal tissue. This study aimed to modulate the inferior right ganglionated plexus (IRGP) of the heart and reduce the ventricular rate during rapid atrial pacing (RAP)-induced atrial fibrillation using ultrasound-mediated BTNPs. Adult male beagles were randomly divided into a phosphate-buffered saline (PBS) group (n = 6) and a BTNP group (n = 6). PBS or nanoparticles were injected into the IRGP of both groups before RAP. The biological safety of the material was evaluated according to electrophysiology recordings, thermal effects and level of inflammation. Compared to the PBS group, the BaTiO3 piezoelectric nanoparticle group had reduced ventricular rates in the sinus rhythm and atrial fibrillation models after stimulating the IRGP by applying ultrasound. In addition, transient stimulation by BTNPs did not lead to sustained neuronal excitation in the IRGP. The activation of the BTNPs did not induce inflammation or thermal damage effects in the IRGP. Ultrasound-mediated BTNP neuromodulation can significantly reduce the ventricular rate by stimulating the IRGP. Thus, ultrasound-mediated BTNP neuromodulation is a potential therapy for atrial fibrillation rate control.

Use of Diltiazem in Chronic Rate Control for Atrial Fibrillation: A Prospective Case-Control Study.

Atrial fibrillation (AF) is a multifaceted disease requiring personalised treatment. The aim of our study was to explore the prognostic impact of a patient-specific therapy (PT) for rate control, including the use of non-dihydropyridine calcium channel blockers (NDDC) in patients with heart failure (HF) or in combination with beta-blockers (BB), compared to standard rate control therapy (ST), as defined by previous ESC guidelines. This is a single-centre prospective observational registry on AF patients who were followed by our University Hospital. We included 1112 patients on an exclusive rate control treatment. The PT group consisted of 125 (11.2%) patients, 93/125 (74.4%) of whom were prescribed BB + NDCC (±digoxin), while 85/125 (68.0%) were HF patients who were prescribed NDCC, which was diltiazem in all cases. The patients treated with a PT showed no difference in one-year overall survival compared to those with an ST. Notably, the patients with HF in ST had a worse prognosis (p &lt; 0.001). To better define this finding, we performed three sensitivity analyses by matching each patient in the PT subgroups with three subjects from the ST cohort, showing an improved one-year survival of the HF patients treated with PT (p = 0.039). Our results suggest a potential outcome benefit of NDCC for rate control in AF patients, either alone or in combination with BB and in selected patients with HF.

Abstract 12553: Adverse Cardiovascular Outcomes in Heart Failure (HF) With Preserved Systolic Function Associated With Atrial Fibrillation Are Due to Loss of Rhythm Control Impacting HF Status : A Propensity Score Matched Analysis of the TOPCAT Americas Study

Background: Atrial fibrillation (AF) is associated with excess mortality and cardiovascular (CV) hospitalizations in HF patients (pts) with preserved systolic function (pEF), Whether this is due to advanced co-morbidities or loss of atrioventricular (AV) synchrony &amp; rate control in AF is unclear. Hypothesis: To analyze the independent impact of AF on clinical outcomes of HFpEF pts in the TOPCAT AMERICAS study using propensity score matched (PSM) cohorts to account for confounding by other comorbidities. Methods: Study cohorts were matched for 20 clinical, demographic &amp; ECG variables. 3 matched cohorts based on baseline rhythm status at study entry were compared viz. subjects in sinus rhythm (SR), subjects in AF on baseline ECG &amp; subjects with Any AF event by history or ECG. We analyzed CV mortality, adjudicated modes of death &amp; morbidity during a mean follow up period of 2.9 yrs. Results: 418 subjects in SR (SR cohort) were PSM with 418 subjects in AF on baseline ECG (AF on ECG cohort) &amp; 418 pts with any AF event by history or ECG (Any AF cohort) at study entry. Any AF increased risk of CV death(D), pump failure death (PFD), CV and HF hospitalization(H) and HF progression. AF on ECG increased risk of CVD, CVH, HFH and PFD (Tables). Neither AF cohort increased risk of sudden death (SD) {Figure}. Conclusion: 1. AF is an independent risk factor for worsening CV outcomes in HFpEF. 2. This increased risk is due to a selective increase in HF worsening, HFH and PFD rather than SD. 3. Loss of AV synchrony &amp; rate control in AF can independently impact HF progression in HFpEF with consequent HFH and PFD. Restoration of SR may offer benefits for CV outcomes in HFpEF &amp; warrants evaluation.

Abstract 13075: Hemodynamic Estimation of Personalized Initial Target Heart Rate in Patients With Atrial Fibrillation With Rapid Ventricular Response

Introduction: Rate control in atrial fibrillation (AF) has played a pivot role in clinical setting even though recent advances in rhythm control. There are few evidences for target heart rate in either acute or chronic situations. Hypothesis: This study tried to estimate personalized initial target heart rate based on hemodynamic assessment in patient with AF with rapid ventricular response. Methods: A total of 72 patients with AF were included. From the equation between preceding RR interval and left ventricular peak ejection velocity adjusted by pre-preceding RR interval, the relationship between cardiac performance representing cardiac output and heart rate was calculated, and heart rate showing maximal cardiac performance (HRmax) was obtained (Left Figure). Results: Mean HRmax was 126±21.8/min (from 75/min to 188/min). Three-fourth patients had HRmax &gt;120/minute (Right Figure). The relationship between Vpe and preceding RR interval showed two types, biphasic or monophasic resulting in similar patterns between cardiac performance and heart rate (Left Figure). HRmax &lt;100/min was found in 7 patients in whom left ventricular dilatation, dysfunction, and/or aortic regurgitation were observed (Left Figure C). Lower HRmax was independently associated with larger aorta size (r=0.48, p&lt;0.001), the absence of mitral regurgitation (r=0.43, p&lt;0.005), prescription of angiotensin converting enzyme inhibitor or angiotensin receptor blocker (r=0.39, p=0.001), and a history of heart failure (r=0.21, p=0.019). Conclusions: In most AF patients, hemodynamic approach suggested that tachycardia of 120/min or more is tolerable. The method of this study may be useful to deliver individually designed management by identifying patient that strict rate control is mandatory. In other patients, management of underlying causes for tachycardia is enough without medications for mechanical heart rate control to avoid adverse effects without clinical benefits.

Abstract 9933: Shifting Paradigms in Rhythm versus Rate Control in Atrial Fibrillation: A Meta-Analysis of Randomized Controlled Trials

Introduction: Atrial fibrillation is the most common cardiac arrhythmia and is an independent risk factor for mortality across a wide age range in both men and women. Management methods of atrial fibrillation have been thoroughly investigated through numerous trials exploring various treatment modalities. There has been a preference for rate control as the initial approach, but recent studies, particularly the EAST-AFNET 4 trial, point out several clinical settings in which rhythm control is preferable. To evaluate new paradigms in the acute management of atrial fibrillation, our meta-analysis provides a current, curated examination of the major landmark trials in the management of atrial fibrillation along with the most recent randomized controlled trials that have been published since 2022. Methods: A literature search was performed on May 2022 using PubMed and OVID Medline databases for study identification. Combinations of the search terms atrial fibrillation, rate control, adrenergic beta antagonists, rhythm control, anti-arrhythmia drugs, and catheter ablation were combined to conduct the literature search. Boolean operators AND and OR were used to combine terms. Results: There were no significant differences in the effects of rate and rhythm control on any outcome: all-cause mortality (RR: 0.996; CI: 0.674-1.376), cardiovascular mortality (RR: 0.957; CI: 0.601-1.413), arrhythmic/sudden death mortality (RR: 0.954; CI: 0.445-1.816), stroke/transient ischemic attack (RR: 1.011; CI: 0.535-1.78), and systemic embolism (RR: 1.275; CI: 0.541-2.625). Conclusions: Updated data pooled from randomized control trials in patients with atrial fibrillation suggests that rhythm and rate control strategies have no statistically significant differences on major clinical outcomes. Additional studies will be required to investigate factors favorable for rhythm-control strategies and to determine contemporary best clinical practices.

Abstract 11096: Impact of Rhythm versus Rate Control in Atrial Fibrillation on All-Cause Mortality, Hospitalization and Stroke: A Systematic Review and Meta-Analysis

Introduction: Many randomized controlled trials (RCTs) compared rate control vs rhythm control therapy in patients with atrial fibrillation (AF). In this study, we systematically reviewed these RCTs and performed a meta-analysis of the outcomes comparing the two therapies. Methods: We searched PubMed, Medline, EMBASE, and SCOPUS databases until April 30, 2022 for all RCTs investigating AF rate vs rhythm control. We used the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) for constructing and reporting this review. We assigned I 2 &gt;50% as an indicator of statistical heterogeneity among the RCTs. We analyzed all-cause mortality, stroke rate, heart failure (HF) hospitalization, and total hospitalization between the two groups. We estimated the risk ratios (RR) with a random-effects model using the Mantel-Haenszel technique and calculated the 95% confidence intervals (CI). A P-value &lt;0.05 was considered significant. All analyses were performed using Review Manager 5.3. Results: Twenty-one RCTs comprising 11,547 patients (77% male) were included. Between the two therapy groups, there was no significant difference in all-cause mortality (RR 1.02 [0.90-1.16], P=0.75 ), HF hospitalization (RR 1.04 [0.83-1.32], P=0.72 ), or stroke rate (RR 1.15 [0.88-1.50], P=0.32 ). Nonetheless, rate control was associated with reduced total hospitalizations (RR 0.77 [0.64-0.94], P=0.01 ). (Figure 1) Conclusions: Atrial fibrillation rate control therapy has similar outcomes to rhythm control in terms of all-cause mortality, HF hospitalization, and stroke rates, but a lower rate of total hospitalizations. Findings are consistent with multiple prior studies showing noninferiority of rate control to rhythm control. Figure 1 - Forest plots highlighting the outcomes of both treatment strategies on AF: A) All-cause mortality, B) Heart failure hospitalization, C) Stroke, and D) Total hospitalization.

Abstract 12571: Optimal Rate Control Strategy in Patients With Atrial Fibrillation: A Meta-Analysis of Randomized Trials and Multivariable Adjusted Studies

Introduction: Atrial fibrillation (AF) is associated with an increased risk of impaired quality of life, stroke, and mortality. Despite multiple studies, the optimal target for rate control in AF is not definitively known. Methods: We performed a systematic review and meta-analysis comparing the effects of strict rate control (&lt;80 bpm at rest) with a lenient rate control strategy (&lt;110 bpm at rest) in patients with AF. The outcomes analyzed were all-cause mortality, cardiovascular (CV) death and CV hospitalization. A subgroup analysis was also performed in patients with heart failure (HF). PubMed, Scopus and Cochrane Central were searched for randomized controlled trials or observational studies with multivariable analyses adjusting for confounders. Results: Seven studies were included. All studies were either randomized or reported multivariate adjusted hazard ratios. There were 14,154 (59.6%) patients in the strict rate control strategy and 9,606 (40.4%) in the lenient group. AF was reported as paroxysmal in 1,697 (7.3%) patients. All-cause mortality was not statistically different between a strict vs. lenient heart rate control strategy, although there was a tendency towards improvement in the strict control group (HR 1.10; 95% CI 1.00-1.22; p=0.05; Figure 1A). In patients with AF and HF, there was also no significant difference between groups (HR 1.13; 95% CI 0.99-1.30; p=0.08; Figure 1B). Furthermore, CV death (HR 0.91; 95% CI 0.75-1.11) and CV hospitalization (HR 1.01; 95% CI 0.96-1.06) were also not significantly different between the two strategies. Conclusions: There was no significant difference in all-cause mortality between strict and leninent rate control in patients with AF among randomized trials or multivariable adjusted studies. In a subgroup of patients with HF, there was also no significant difference between the two rate control strategies.

Rhythm versus rate control for atrial fibrillation in heart failure with preserved ejection fraction.

There are few prospective studies assessing the benefits of rhythm control of atrial fibrillation (AF) in patients with heart failure and preserved ejection fraction (HFpEF), which accounts for 50% of all heart failure patients. Conduct a meta-analysis to assess the effects of rhythm control (ablation and/or antiarrhythmic medications) vs rate control on all-cause mortality in AF patients with HFpEF. Databases were searched for studies reporting the effect of rhythm control vs rate control on mortality in patients with HFpEF (Ovid MEDLINE, EMBASE, Scopus, Web of Science, Google Scholar, and EBSCO CINAHL). The search was not restricted to time or publication status. The primary endpoint was all-cause mortality. The minimum duration of follow-up required for inclusion was 1 year. The literature search identified 1210 candidate studies; 5 studies and 16,825 patients were included. The study population had 57% men with a mean age of 71± 2.5 years. Rhythm control for AF was associated with lower all-cause mortality (odds ratio 0.735, 95% confidence interval 0.665-0.813; P < .001) as compared to rate control. Rhythm control for AF in patients with HFpEF was associated with decreased all-cause mortality.

What is the Best Agent for Rate Control of Atrial Fibrillation With Rapid Ventricular Response?

BackgroundAtrial fibrillation (AF) is a common dysrhythmia associated with significant morbidity and mortality. Although many patients have stable AF, some patients can present with a rapid ventricular response (RVR). In these patients, it is important to lower their heart rate. However, there are several options available for rate control in the emergency department setting. Clinical QuestionWhat is the most effective agent for rate control for the patient with AF in RVR? Evidence ReviewStudies retrieved included two prospective, randomized, double-blind studies and six retrospective cohort studies. These studies provide estimates of the efficacy and safety of calcium channel blockers and β-blockers for rate control in those with AF with RVR. ConclusionBased upon the available literature, diltiazem likely achieves rate control faster than metoprolol, though both agents seem safe and effective. Clinicians must consider the individual patient, clinical situation, and comorbidities when selecting a medication for rate control.